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Guthrie AJ, Paredes-Echeverri S, Bleier C, Adams C, Millstein DJ, Ranford J, Perez DL. Mechanistic studies in pathological health anxiety: A systematic review and emerging conceptual framework. J Affect Disord 2024; 358:222-249. [PMID: 38718945 PMCID: PMC11298870 DOI: 10.1016/j.jad.2024.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 04/02/2024] [Accepted: 05/02/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Pathological health anxiety (PHA) (e.g., hypochondriasis and illness anxiety disorder) is common in medical settings and associated with increased healthcare costs. However, the psychological and neurobiological mechanisms contributing to the development and maintenance of PHA are incompletely understood. METHODS We performed a systematic review to characterize the mechanistic understanding of PHA. PubMed, PsycINFO, and Embase databases were searched to find articles published between 1/1/1990 and 12/31/2022 employing a behavioral task and/or physiological measures in individuals with hypochondriasis, illness anxiety disorder, and PHA more broadly. RESULTS Out of 9141 records identified, fifty-seven met inclusion criteria. Article quality varied substantially across studies, and was overall inadequate. Cognitive, behavioral, and affective findings implicated in PHA included health-related attentional and memory recall biases, a narrow health concept, threat confirming thought patterns, use of safety-seeking behaviors, and biased explicit and implicit affective processing of health-related information among other observations. There is initial evidence supporting a potential overestimation of interoceptive stimuli in those with PHA. Neuroendocrine, electrophysiology, and brain imaging research in PHA are particularly in their early stages. LIMITATIONS Included articles evaluated PHA categorically, suggesting that sub-threshold and dimensional health anxiety considerations are not contextualized. CONCLUSIONS Within an integrated cognitive-behavioral-affective and predictive processing formulation, we theorize that sub-optimal illness and health concepts, altered interoceptive modeling, biased illness-based predictions and attention, and aberrant prediction error learning are mechanisms relevant to PHA requiring more research. Comprehensively investigating the pathophysiology of PHA offers the potential to identify adjunctive diagnostic biomarkers and catalyze new biologically-informed treatments.
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Affiliation(s)
- Andrew J Guthrie
- Functional Neurological Disorder Unit, Division of Behavioral Neurology and Integrated Brain Medicine, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sara Paredes-Echeverri
- Functional Neurological Disorder Unit, Division of Behavioral Neurology and Integrated Brain Medicine, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cristina Bleier
- Functional Neurological Disorder Unit, Division of Behavioral Neurology and Integrated Brain Medicine, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Caitlin Adams
- Functional Neurological Disorder Unit, Division of Behavioral Neurology and Integrated Brain Medicine, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel J Millstein
- Functional Neurological Disorder Unit, Division of Behavioral Neurology and Integrated Brain Medicine, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jessica Ranford
- Functional Neurological Disorder Unit, Division of Behavioral Neurology and Integrated Brain Medicine, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Occupational Therapy, Massachusetts General Hospital, Boston, MA, USA
| | - David L Perez
- Functional Neurological Disorder Unit, Division of Behavioral Neurology and Integrated Brain Medicine, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Division of Neuropsychiatry, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Shen Z, Yu L, Zhao Z, Jin K, Pan F, Hu S, Li S, Xu Y, Xu D, Huang M. Gray Matter Volume and Functional Connectivity in Hypochondriasis: A Magnetic Resonance Imaging and Support Vector Machine Analysis. Front Hum Neurosci 2020; 14:596157. [PMID: 33343319 PMCID: PMC7738430 DOI: 10.3389/fnhum.2020.596157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/23/2020] [Indexed: 12/19/2022] Open
Abstract
Objective: Patients with hypochondriasis hold unexplainable beliefs and a fear of having a lethal disease, with poor compliances and treatment response to psychotropic drugs. Although several studies have demonstrated that patients with hypochondriasis demonstrate abnormalities in brain structure and function, gray matter volume (GMV) and functional connectivity (FC) in hypochondriasis still remain unclear. Methods: The present study collected T1-weighted and resting-state functional magnetic resonance images from 21 hypochondriasis patients and 22 well-matched healthy controls (HCs). We first analyzed the difference in the GMV between the two groups. We then used the regions showing a difference in GMV between two groups as seeds to perform functional connectivity (FC) analysis. Finally, a support vector machine (SVM) was applied to the imaging data to distinguish hypochondriasis patients from HCs. Results: Compared with the HCs, the hypochondriasis group showed decreased GMV in the left precuneus, and increased GMV in the left medial frontal gyrus. FC analyses revealed decreased FC between the left medial frontal gyrus and cuneus, and between the left precuneus and cuneus. A combination of both GMV and FC in the left precuneus, medial frontal gyrus, and cuneus was able to discriminate the hypochondriasis patients from HCs with a sensitivity of 0.98, specificity of 0.93, and accuracy of 0.95. Conclusion: Our study suggests that smaller left precuneus volumes and decreased FC between the left precuneus and cuneus seem to play an important role of hypochondriasis. Future studies are needed to confirm whether this finding is generalizable to patients with hypochondriasis.
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Affiliation(s)
- Zhe Shen
- Department of Psychiatry, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- The Key Laboratory of Mental Disorder’s Management of Zhejiang Province, Hangzhou, China
- Zhejiang Engineering Center for Mathematical Mental Health, Hangzhou, China
| | - Liang Yu
- Department of Anesthesiology and Pain, The Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhiyong Zhao
- Key Laboratory for Biomedical Engineering of Ministry of Education, Department of Biomedical Engineering, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Kangyu Jin
- Department of Psychiatry, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- The Key Laboratory of Mental Disorder’s Management of Zhejiang Province, Hangzhou, China
- Zhejiang Engineering Center for Mathematical Mental Health, Hangzhou, China
| | - Fen Pan
- Department of Psychiatry, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- The Key Laboratory of Mental Disorder’s Management of Zhejiang Province, Hangzhou, China
- Zhejiang Engineering Center for Mathematical Mental Health, Hangzhou, China
| | - Shaohua Hu
- Department of Psychiatry, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- The Key Laboratory of Mental Disorder’s Management of Zhejiang Province, Hangzhou, China
- Zhejiang Engineering Center for Mathematical Mental Health, Hangzhou, China
| | - Shangda Li
- Department of Psychiatry, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- The Key Laboratory of Mental Disorder’s Management of Zhejiang Province, Hangzhou, China
- Zhejiang Engineering Center for Mathematical Mental Health, Hangzhou, China
| | - Yi Xu
- Department of Psychiatry, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- The Key Laboratory of Mental Disorder’s Management of Zhejiang Province, Hangzhou, China
- Zhejiang Engineering Center for Mathematical Mental Health, Hangzhou, China
| | - Dongrong Xu
- Columbia University and New York State Psychiatric Institute, Riverside Drive, New York, NY, United States
| | - Manli Huang
- Department of Psychiatry, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- The Key Laboratory of Mental Disorder’s Management of Zhejiang Province, Hangzhou, China
- Zhejiang Engineering Center for Mathematical Mental Health, Hangzhou, China
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Chappell AS. Toward a Lifestyle Medicine Approach to Illness Anxiety Disorder (Formerly Hypochondriasis). Am J Lifestyle Med 2018; 12:365-369. [PMID: 30283260 DOI: 10.1177/1559827618764649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Lifestyle medicine may be the most effective way of treating illness anxiety disorder (IAD), formerly hypochondriasis. IAD as defined in the DSM-5 can now be diagnosed using positive symptoms, which means it is no longer a diagnosis of exclusion. Tools used in lifestyle medicine including motivational interviewing and mindfulness based stress reduction (MBSR) may be particularly useful in the management of IAD.
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Hippocampus and amygdalar volumes in patients with somatization disorder. Prog Neuropsychopharmacol Biol Psychiatry 2011; 35:1699-703. [PMID: 21651951 DOI: 10.1016/j.pnpbp.2011.05.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Revised: 04/24/2011] [Accepted: 05/25/2011] [Indexed: 01/08/2023]
Abstract
In regard to somatization disorder which covers an important section of our patient population, there is no systematic structural magnetic resonance imaging (MRI) study in the literature. Therefore, we aimed to use structural MRI to evaluate the hippocampus amygdalar complex which is associated with both stress and regulation of emotion that are main basis clinical presentation of somatization disorder in the patients with somatization disorder. Totally 40 subjects (20 patients with somatization disorder and 20 healthy controls) were enrolled. Intracranial volume (ICV), whole brain volume, gray and white matter volumes, and hippocampus and amygdalar volumes of the subjects were measured. In regard to unadjusted mean volumes of measured structures, the patients had significantly smaller mean volumes of the left and right amygdala. However, two groups did not differ significantly in terms of whole brain, total gray and white matter or hippocampus volumes. The repeated measures ANCOVA predicting left and right amygdala volumes demonstrated a significant main effect of diagnostic group. In conclusion, the findings of the present study revealed that the patients with somatization disorder had significantly smaller mean volumes of the left and right amygdala without any differences in regard to whole brain, total gray and white matter or hippocampus volumes. On the basis of the current findings, it seems reasonable to evaluate that abnormalities in connectivity and/or metabolism dimensions and to examine the effects of drugs or psychotherapeutic approaches could be especially informative.
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